Monthly Archives: December 2019

Understanding stillbirth

By Samantha Rouse December 5, 2019

What if there was a trauma that affected 25% of our adult female clients? Wouldn’t we want to know about it? This isn’t just a hypothetical for counselors, yet chances are that we as clinicians are ill-prepared to effectively identify and treat our clients who fall into this population.

In the United States, 1 in 4 women experiences some form of infant or pregnancy loss. Included in this statistic are the more than 26,000 women who experience a stillbirth each year. A stillbirth occurs late term after an otherwise healthy baby could have survived outside of the womb. Stillbirth often is defined as the death of a baby after 26 weeks’ gestation.

Long before my decision to get my education and become a professional counselor, I became one of those 26,000 mothers. It was only natural that the area of stillbirth would become an area of interest for my own research during my doctoral studies. It was my experience in my job, however, that led me to see the gaping hole in our field of professionals who are competent and knowledgeable enough to provide help. Each time a new referral came in that had reported any kind of pregnancy loss, she was immediately referred to me. This was because most people hold one of two positions: 1) The person who has experienced what the client is experiencing is the best person to help the client, or 2) I cannot help someone with something that I have never experienced myself.

This flawed referral process creates an issue with our profession being able to provide quality care to clients who have experienced stillbirth. Referral of these clients solely to those counselors who have experienced stillbirth themselves can be harmful to both the client and the counselor. The counselor may become overwhelmed at the number of clients with this specific need so close to her own traumatic experience, potentially resulting in burnout for the clinician. An equally disturbing result of this referral process is that other counselors are denied the opportunity to treat and learn from this population. This keeps the number of competent counselors lower than is needed.

Understanding the trauma

The death of a child is an unexplainable pain. Author Jay Neugeboren famously wrote, “A wife who loses a husband is called a widow. A husband who loses a wife is called a widower. A child who loses his parents is called an orphan. There is no word for a parent who loses a child. That’s how awful the loss is.” It feels unnatural for parents to outlive their children, regardless of the child’s age when he or she dies. However, stillbirth presents unique characteristics that make this scenario even more complicated for bereaved parents.

The experience of stillbirth has a high level of ambiguity. The death of a baby leaves so much unknown, and mothers often find themselves wondering why their baby died, what their baby would have looked like had he or she grown up, what the child’s voice would have sounded like, and how their family would have been different had the child lived. This ambiguity often leads to the death having a lack of meaning, in that the mother is often searching for the purpose of the child’s life. Mothers might repeatedly ask themselves questions such as “Why me?” or “Why did God give me a baby just to have it die?”

Stillbirth does not involve only grief; it also involves a trauma or multiple traumas. Most people think that stillbirth occurs when the parents are told at delivery that their baby was born dead. This is not the case with modern medicine. Typically, the parents are alerted to the death of their baby before the delivery, and the mother then has her labor induced. The news of hearing that their baby is dead begins the first trauma.

The trauma continues during labor and delivery, which is now the antithesis of the joyful experience the mother had anticipated over the course of her pregnancy. Sorrow and silence replace what were once expected to be feelings of elation and the sounds of a new baby crying. After the painful experience of the labor and delivery, the mother is given the option of seeing her baby. Depending on how long it has been since the baby died, the appearance of the baby might be affected. Some mothers choose to see the baby and will hold, rock and take pictures of their child.

After delivery, the mother is moved into a room that is often located within the labor and delivery area. The trip from the delivery room to her recovery room exposes the mother to sights and sounds such as banners proclaiming “It’s a boy!” and other families’ loved ones cheerfully gathering in the hallways to see their own bundles of joy. The grieving mother’s room is empty and silent. Her door remains shut in an attempt to drown out the sound of crying newborns from other rooms.

After a couple of days of hospital care, the mother is sent home and must tend to her recovering body. In the days that follow, she will develop the same physical response to childbirth that a mother with a living child would. Mothers who have experienced stillbirth are often encouraged to bind their breasts to “dry up” their milk.

Within a day of delivery, the mother must make decisions about the autopsy and burial options for her baby. The mother must wrestle with the decision to keep the casket open or closed during the funeral or burial service. This decision is often based on the appearance of the infant at birth (because the skin of a baby who is stillborn is frequently affected). A tiny casket is often presented and seems out of place in the environment of the funeral home.

If the mother or father is employed, their time off goes by quickly before they must return to what is expected to be their “normal” life. In many cases, paid time off or bereavement leave is not provided to these parents because the stillborn child was never considered a living person. The parents do not receive a birth or death certificate for their child for the same reason. For a birth certificate to be given, the baby must have shown signs of life after delivery, even if it was only for one breath or heartbeat. In most states, a stillborn baby cannot be claimed as a dependent for tax purposes. (Tip: Some states offer a “stillbirth certificate”; this may be a resource for clients if appropriate for their treatment.)

Best practices for screening

In many practices, the intake process includes a generic demographic question for reporting family size. This might include a fill-in-the-blank option for the client’s number of children or number of living children. (Tip: Replace “number of children” with “number of pregnancies, number of live births, and number of living children.” This ensures that all areas — miscarriage, stillbirth or the later death of a child — are covered.)

Screening for stillbirth through the demographic paperwork is the first step. This initial paperwork offers a small glimpse into the client’s full story. Reviewing the paperwork prior to the initial clinical interview will alert the clinician to the need to discuss the client’s experience of stillbirth (if the client discloses it in the paperwork).

The clinical interview can be difficult for both the counselor and the client when it comes to discussing a stillbirth. Because of social expectations and the ambiguity of their loss, women are less likely to report a stillbirth than they are other experiences. It is much easier for a person to put a number on the intake paper regarding number of pregnancies and number of living children than it is to openly bring up a stillbirth during the clinical interview. For this reason, direct questioning on the part of the counselor is vital.

Counselors may initially find it uncomfortable to directly ask clients about any type of pregnancy loss. It is important for counselors to practice using the correct terminology and language appropriate for a stillbirth. Additionally, they should get comfortable with other terms that the mother might use, such as died, death, dead baby, dead child, etc. It may be beneficial for counselors to practice using these terms out loud with a trusted person to become more comfortable saying them. When counselors are comfortable discussing stillbirth and other pregnancy loss, clients are likely to recognize this and move to a higher level of openness about their own experiences sooner rather than later. This allows for the therapeutic relationship to develop at a faster pace, leading to more rapid treatment results and a higher client retention rate.

For many clients, the disclosure of a stillbirth might happen later on or might never happen, due in large part to societal views of stillbirth (e.g., they do not “count,” they never existed, mothers must “move on”). This will hamper the overall depth of the therapeutic relationship and can also prevent appropriate treatment of the trauma.

Need-to-know factors

As counselors, it is our responsibility to ensure that we are knowledgeable about the variety of issues that our clients face. With such a high prevalence of stillbirths, it is important that we truly understand this experience to provide competent treatment. There are several key points of which counselors need to be aware.

>>  Social supports: Not surprisingly, the presence of strong social supports has shown to be an important factor in a person’s recovery following a stillbirth. These supports can include a spouse or significant other, family members, friends, and involvement in a church or religious community. A person’s support system often diminishes following a stillbirth because of the “hushed” nature of the experience.

>>  Use of clients’ language: Mothers of stillborn babies will often give their babies a name. If the client uses the baby’s name in session, the counselor needs to refer to the stillborn child by name and not as “the baby.” The mother may be hesitant to speak the baby’s name, again due to the hushed nature of stillbirth. It can benefit the therapeutic relationship for the counselor to ask, “What would you like for me to call the baby?” This also avoids the question, “Did you name the baby?” which could imply that the mother should feel ashamed if she did not name the child.

>>  Suicidality: Mothers who have experienced a stillbirth often report feeling like “I want to go to sleep and not wake up” or “I don’t want to live anymore.” It is important to understand the difference between these thoughts and active suicidal ideation. This is especially important because these mothers often experience postpartum depression along with the grief and trauma from the stillbirth.

>>  Postpartum depression: Mothers who deliver stillborn babies are not exempt from postpartum depression. This can lead to the complex issue of depression tied with grief, trauma and, sometimes, psychosis. Many people, including clinicians, make the mistake of assuming that these mothers are dealing with “only” grief, “only” postpartum depression, etc.

>>  Trauma: Stillbirth is often thought of as producing grief or depression. Approaching it only from this lens, rather than also understanding the trauma associated with the experience, can cause treatment to be ineffective. This limited approach can also prevent the client from feeling fully understood, leading to a poor therapeutic relationship.

>> Comfort terms: The experience of stillbirth is often silenced and met with a “move on” expectation in society. In part for that reason, it is important for counselors to recognize and avoid using common comfort terms. These include:

  “At least you know you can get pregnant.”

  “This was part of a plan.”

  “Thank goodness you have your other children.”

  “It wasn’t meant to be.”

  “There might have been something wrong with it.”

>>  Long-term presence: The mother’s close relationships may become strained or even dissolve in the aftermath of the stillbirth experience. Divorce rates have also been found to be influenced by the experience of stillbirth. If not dealt with, the trauma associated with stillbirth can manifest as a personality disorder or a substance use disorder.

Treatment considerations

The complex nature of the stillbirth experience often leaves counselors feeling lost regarding the potential direction for treatment. Many interventions used in treating grief are applicable with these clients, and other interventions typically used to treat depression and anxiety can also be used.

For example, let’s say that a counselor has a new client beginning services six months after her first child was stillborn. She was referred by her primary care doctor when she made an appointment with the doctor to obtain medication. She is married with no living children, comes from a large family, and attends a nondenominational church regularly. The client reports that she had to quit her job because she was unable to focus and would cry throughout the day. The client discloses that she had a stillborn daughter named Sarah. A funeral and burial were held, but the client says she is unable to “move on.”

The client’s faith and large family can serve as protective factors because they provide her with a large support system. At the same time, they can also be risk factors by triggering the client and reminding her of her loss. One option is to explore with the client whether she has any frustrations with her support system or any negative beliefs and thoughts about herself when around her support system. The client might reply that she wants to avoid being around babies and small children at family gatherings and church services. The counselor shouldn’t then turn the focus to helping the client find ways to cope with being around babies and children because this might send a message of “get over it” to the client. Instead, the counselor could explore the client’s feelings of unjustness and hurt, both providing validation and normalizing how she feels. The counselor would then allow the client to decide on the small steps she wants to take.

A significant amount of ambiguity accompanies the experience of stillbirth. Some clients are comforted by finding meaning in their loss, while others are not. The counselor can explore this with the client and should be aware that the client’s feelings may change back and forth as time passes. If the client cannot attribute any meaning to her loss or does not find comfort in the meaning, the counselor should validate her feelings of unfairness, hurt and anger and empower her to create her own meaning. For example, how can the client use this meaningless loss for good in the future?

It is often helpful to encourage the use of rituals with clients. This particular client named her baby and also had a funeral and burial for her. The counselor could explore ways the client might use other rituals as a means of keeping her daughter a part of her life. For example, she could hang pictures of her daughter in her home, keep a photo of her daughter in her car, visit the cemetery regularly, have an object such as a candle or decoration that represents the daughter during holidays, and so on.

The counselor could also introduce the client to online resources and supports. This may provide a sense of normalization to the client and counteract her feelings of being isolated in her pain. It may also provide a network that can offer creative ideas for rituals.

There are many ways to approach counseling with these clients, but there are also things to avoid. For instance, counselors should avoid bringing in their own beliefs and expectations for these clients (just as with any clients). These mothers should not feel rushed or be made to feel guilty for not getting “better” sooner. Counselors should avoid using the common comfort terms listed earlier. Counselors must also keep in mind that the therapeutic relationship is more important than any particular technique, and they should allow these clients to be actively engaged in deciding what their sessions are like.

Every mother’s experience of stillbirth is different. The mother’s family, religious beliefs and culture all influence her response to the stillbirth. Additionally, her experience is influenced by the protocol of the medical facilities where she delivered and the attitudes of the health care providers involved. Counselors should address all of these factors in session to ensure that mothers are being treated appropriately for their individual experiences. Our society tends to “hush” these mothers and their experiences because stillbirth is so uncomfortable to address. However, these mothers need to be heard, understood and validated as being mothers, even if they have no other living children. After all, born still is still born.

 

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Samantha Rouse is a licensed professional clinical counselor working for Hosparus Health in central Kentucky. She is a fourth-year doctoral student at Lindsey Wilson College doing research on motherhood and stillbirth. Contact her at samantha.rouse@lindsey.edu.

 

Letters to the editor:  ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Maintaining counselor identity in interdisciplinary teams

By Princess Lanclos and Krystal Vaughn December 3, 2019

Professional counselors are increasing their presence in a variety of settings, including nonprofit agencies, clinics, private practice groups, schools, hospitals, and state and federal vocational rehabilitation centers. In these settings, counselors are likely to work with other health care professionals for the benefit of their clients. Some of these other professionals involved in the care of clients may include physicians, speech therapists, occupational therapists, and case managers. As we enter into new arenas, our ability to advocate for the counseling profession is imperative, yet many counselors may find themselves questioning how to do that while working in interdisciplinary teams.

One way that advocacy may be achieved in an interdisciplinary team is through active implementation of a shared decision-making model. According to research conducted by France Légaré in 2011, shared decision-making models have historically focused on the patient-physician dyad.

Both medical professionals and professional counselors are trained to make decisions to benefit their clients. However, counselors are typically trained to use an ethical decision-making model such as Holly Forester-Miller and Thomas Davis’ seven-step process:

1) Identify the problem.

2) Apply the ACA Code of Ethics.

3) Determine the nature and dimensions of the dilemma.

4) Generate potential courses of action.

5) Consider the potential consequences of all options and determine a course of action.

6) Evaluate the selected course of action.

7) Implement the course of action.

Medical professionals, on the other hand, may be trained to use a medical decision-making model. This model involves 1) the number of potential diagnoses and management options that must be considered during an encounter, 2) the amount and complexity of data to be reviewed as a result of the encounter, and 3) the risk of complications, morbidity and mortality associated with the encounter.

Alternatively, medical professionals may use a shared decision-making model. This model first determines if the decision is the right thing to do ethically. Next, the patient is provided with treatment options so that the patient can make an informed decision. Consent is then obtained. This model helps bridge health disparities by involving patients in many aspects of the treatment, including the informed decision-making process.

All of these decision-making methods share similarities, including placing emphasis on four common principles: autonomy, justice, beneficence and nonmaleficence. Additionally, both the ACA Code of Ethics and the American Medical Association’s code of medical ethics strive to protect the confidentiality of the client/patient. In The American Journal of Emergency Medicine in 2016, Chadd Kraus and Catherine Marco defined shared decision-making as a collaborative process that allows patients (or their surrogates) and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals and preferences.

Therefore, in an interdisciplinary team, a professional counselor may offer a unique perspective to benefit the client or patient. This can lead to counselors advocating for themselves and their profession. The question is, how do we bring awareness to these variations in decision-making models on the basis of any health care professional’s training program while also effectively training and implementing these approaches for both new and seasoned health care professionals?

Classroom

Professional identity and ethical decision-making begin early in a counselor-in-training’s academic career and are specifically reinforced in CACREP-accredited graduate training programs. These programs are composed of core courses (e.g., ethics, counseling techniques, assessment) that allow students to begin exploring and implementing the skills needed to handle ethical dilemmas. At this stage of professional development, graduate students are establishing ethical decision-making practices and the principles of autonomy, nonmaleficence, beneficence and justice, which are reinforced throughout their academic careers (e.g., practicum, internships).

Additionally, the opportunity to practice implementing a shared decision-making model may be offered in a classroom setting by engaging students in activities or courses in which they join with students from other disciplines to approach a case study and propose a holistic treatment plan that addresses each discipline’s scope of practice. Engrossing students in this practice may aid in postgraduate work and provide them a new perspective and appreciation for various treatment providers who might be serving their clients.

However, unless a student is placed at a practicum or internship site where multiple disciplines are offering services, the student may receive little guidance related to working within an interdisciplinary team. Therefore, we encourage counseling training programs to initiate relationships with potential internship sites that feature multiple disciplines so that students can experience the benefits and challenges of working within interdisciplinary teams. Alternatively, students could be placed at internship sites that actively consult with other treatment providers outside of the internship site.

Post-graduation

Think back to your first job after graduation or even to your current place of employment. Did/does your agency offer an opportunity for interdisciplinary consultation or encourage you to consult with a client’s treatment team in another health care setting? As a beginning professional in the field of counseling, did you feel comfortable discussing your treatment recommendations with another professional?

As members of interdisciplinary teams, counselors should understand not only the challenges but also the benefits of shared decision-making models in conjunction with an ethical decision-making model of their choice. Each of these models benefits the client and the field of counseling.

Implementing model and consultation

Many individuals are trained in graduate school to interact with the identified client but may have limited exposure to working within an interdisciplinary or interprofessional team. However, the reality is that the clients we see today may have a variety of treatment providers (speech therapists, occupational therapists, case workers, physicians, psychologists, etc.). It takes practice and experience to maintain our counselor identity while engaging in consultation with other treatment providers. Exploring instances in which consultation is needed and how it is implemented may aid in providing and advocating for quality holistic treatment for clients.

Consultation first requires knowledge of the treatment team. Who is the client working with outside of your agency or clinic? Do you have consent to speak with that individual in accord with Health Insurance Portability and Accountability Act (HIPAA) considerations? Counselors must reflect on how consulting with the treatment provider would aid in the client’s treatment. At times, we may consult to share treatment goals or treatment progress. However, at other times, we are consulting to gain information regarding another professional’s goals, methods or protocols. Once a working relationship is developed, the counselor may proceed to engage in the initial phase of consultation.

Step one: The initial phase of consultation should include preparing for the call, including ensuring that all proper HIPAA release of information and agency paperwork have been completed. The counselor should be prepared with a concise yet well-thought-out reason for requesting consultation. What information would the counselor like to share or request? The counselor may also want to consider whether the person being consulted understands that the counselor is also working with the individual and how the counselor’s role relates to the treatment of the individual. 

Step two: The counselor should contact the consulting agency, provide the release of information, and schedule a consultation. Scheduling may be essential because many professionals are busy and might not be readily available to speak. It sometimes requires numerous phone calls to contact the individual provider. Even if the provider is available, he or she may not have the client’s chart or may still need to review the information, potentially causing frustration and delays. Therefore, if a call is scheduled, all parties should be prepared to participate fully.

Step three: The requesting provider should be well-prepared with information that might be shared or requested during the consultation call. A brief overview of how the client came to receive services from the counselor and what services the counselor is providing is a nice place to start. This should be followed by discussing the client’s condition, interventions, shared treatment goals, schedule/frequency of treatment, prognosis, and expected duration of treatment. At times, professionals may have similar treatment goals for the client but might be using different interventions or approaches. It is important to recognize that overlap may exist in the knowledge and skills of each provider. In such cases, it may be necessary to discuss why the providers and treatment modalities are mutually beneficial to the client. During the consultation, it may also be important to consider alternative or complementary therapies.

The counselor may be seeing the client more frequently than is the other provider, so a general impression of the client’s current condition and presentation may be helpful to the overall treatment team. The consultation call should allow the counselor to ask questions of the other providers and vice versa. Consultations can be held individually or with all members of the treatment team, depending on the levels of intervention and the specific consultation questions being asked.

Treatment teams may need to determine who will be responsible for which treatment goals or objectives. (Note: Professional counselors must be careful to stay clearly within their scope of practice.) At this point, it may also be important to schedule a follow-up consult, if necessary, and determine which of the treatment providers will start the call. Follow-up consults work best when they are planned, scheduled and predictable. This allows providers to align treatment goals and outcomes.

Step four: The counselor should document consultations in the client’s file. The consultation notes should include the name of the client, date and time of the call, and length of the call. The purpose of the call should also be clearly noted and supported by HIPAA release of information documentation. We recommend also dedicating a space on the consultation documentation form for a narrative that states the overview and outcome of the consult.

Case example

Sally is a 12-year-old female who is seeing a licensed professional counselor to help her reduce her anxiety symptoms. Initially, a licensed clinical psychologist diagnosed Sally with generalized anxiety disorder (GAD) and a speech language disorder and then referred her for speech, counseling, and medication evaluation. Sally lives at home with her parents and doesn’t have any siblings. The counselor would like to speak with Sally’s psychologist, school counselor, speech therapist, and treating child psychiatrist. The counselor requested that Sally’s parents sign HIPAA forms during the initial intake session.

Step one: After treating Sally for two to three sessions, the counselor forms consultation questions for each provider treating Sally. The counselor first would like to know from the psychologist whether Sally has any educational limitations that would prevent her from participating in cognitive behavior therapy. Second, the counselor would like to know how the school is addressing Sally’s symptoms of GAD, whether an accommodation plan is being or has been used for Sally, and whether the school counselor is working with Sally weekly. Third, the counselor would like to know whether the speech therapist is noticing signs of GAD during sessions with Sally and, if so, how the speech therapist is addressing those symptoms. Finally, the counselor would like to know what recommendations the psychiatrist has, while also providing the psychiatrist with information on Sally’s progress and the techniques being used in the counseling sessions.

Step two: The counselor will contact each of the four providers’ offices to request a consultation call. The counselor will also scan or fax the HIPAA release to each provider in a secure manner.

Step three: The counselor will review the file, treatment goals, progress, and schedule/frequency of treatment for Sally. The counselor should have questions prepared or outlined for each of the consultation calls. It will be important for members of Sally’s treatment team to consider how the various treatments may support one another, be similar, or be different. The team should also consider how often consultation will need to occur and who will be responsible for scheduling. For example, the psychologist may not have any additional contact with the family and require no further communication with the treatment team. However, the school counselor and speech therapist may be seeing Sally weekly, similar to the counselor. Therefore, frequent contact between these three providers may be necessary. Finally, the psychiatrist may request information only immediately prior to Sally’s next appointment.

Step four: The counselor will document each consult. The note should include the date and time of each consult, a summary of the consult, and the next scheduled consultation.

Conclusion

Using the aforementioned instructions while consulting with other health care professionals may aid in applying a decision-making model that will continue to benefit the clinician, the client, and the counseling profession as we continue to adapt and improve our provision of treatment for the populations we serve.

As professional counselors, we may find ourselves working alongside other professionals who hold more advanced degrees. Regardless, it is important that we maintain our counselor identity, uphold our professional code of ethics, and advocate for our clients’ well-being. When involved in interdisciplinary teams, it is imperative that we are able to work within our scope of practice as counselors and clearly state the rationale for the interventions we are providing in therapy. Additionally, implementing a shared decision-making model fosters an opportunity for us to advocate for our profession and our clients while in interdisciplinary settings.

 

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Princess Lanclos is a doctoral student in counselor education and supervision at the University of Holy Cross in New Orleans. She is a national certified counselor, a certified rehabilitation counselor, and a provisionally licensed professional counselor. Her areas of focus include substance abuse, counseling ex-offenders, and multicultural counseling. Contact her at princess_lanclos@uhcno.edu.

Krystal Vaughn is a licensed professional counselor supervisor specializing in working with children ages 2-12. As an associate professor at Louisiana State University Health Sciences Center–New Orleans, she enjoys teaching and providing clinical services. Her research interests include supervision, play therapy, and mental health consultation. She has extensive experience providing mental health consultation in child care centers, private schools, and local charter school systems. Contact her at kvaugh@lsuhsc.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conference.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Human rights 101, Part 2: Implications for graduate students and counselor education programs

By Clark D. Ausloos and Taylor Nelson December 2, 2019

Part one of our two-part series provided a foundation of the importance of human rights, the relevance to professional counseling, and practical strategies to use when working with clients who have experienced human rights violations. Part two focuses on human rights, social justice and advocacy related to counseling graduate students and counselor education programs.

Many people enter the counseling profession because they have a desire to help people. They have a knack for listening and possess a genuine curiosity for the human condition. Many students have a passion for mending, repairing and supporting others towards self-actualization. In many introductory graduate classes, students explore the foundations of the counseling profession, learning about psychotherapy pioneers such as Sigmund Freud, Carl Jung, Alfred Adler, Frank Parsons, and Carl Rogers, and learn necessary basic skills in order to best help clients.

However, graduate students are not often given clear direction on how to execute one essential ethical mandate dictated in the ACA Code of Ethics: to “advocate at individual, group, institutional, and societal levels to address barriers and obstacles that inhibit access and/or the growth and development of clients” (A.7.a). Advocacy can seem confusing and challenging to graduate students – some might even think: I didn’t become a counselor to engage in advocacy. Many graduate students are unclear as to the multifaceted roles that counselors have, including the component of advocacy as it relates to human rights issues. This lack of clarity is not unfounded  –  professional counselors often lack consensus on how best to advocate for and on behalf of their clients’ human rights.

Multiculturalism, social justice and human rights

Counseling is a young profession and has seen many developments throughout the years. Starting in the late 1980s, professional counselors saw a need for attention to diversity in clinical and educational settings. Increasingly, counselors were diagnosing and treating individuals who differed culturally from themselves. Therefore, the needs of the profession shifted, however slowly, to meet the needs of consumers. At that time, scholarship focused on racial and ethnic identities in counseling, and mainly examined the relationship between a professional counselor’s ethnocultural identity and that of the client. In the 1990s, Garry Walz and colleagues identified significant trends that should inform future counseling, including developing skills in counseling older adults, counseling family systems, a commitment to multiculturalism, and most salient to this article, the development of advocacy skills.

In 1992, ACA’s first Multicultural Counseling Competencies (MCC) were developed for professional counseling. Becoming competent in multicultural counseling would require counselors to not only understand and honor the diverse customs of different cultures but to recognize the additional barriers many client groups faced. Meeting the needs of disadvantaged clients would require not just knowledge, but action. In 1998, the American Counseling Association (ACA) formed a new division — Counselors for Social Justice (CSJ)— to implement social action strategies aimed at the empowerment of clients and oppressed individuals and groups. With the increasing awareness that social justice concerns must take a prominent role in the profession, the need for individual counselors to gain competency became clear. Because social justice and multicultural issues are inherently linked, the competencies were incorporated into an adapted version of the MCC in 2015, creating the Multicultural and Social Justice Counseling Competencies (MSJCC). At the same time awareness of the importance of advocacy—both for the profession itself and for counselors’ work with clients—was growing and became a focus for ACA leaders. A task force was created to develop advocacy competencies. The ACA Advocacy Competencies were completed in 2003 to provide guidance for counselor advocacy at the micro (e.g., clients, students), meso (e.g., communities, organizations), and macro (e.g. to reflect the profession’s growing understanding of the use of advocacy with clients and their communities and were updated in 2018.

Still, with all of this information, graduate students may be left wondering, “what exactly does this mean for me?”

As mentioned in part one of our series, human rights are civil, political and/or cultural rights that are afforded to humans regardless of our intersecting identities. When these rights of our clients are violated, there are tremendous mental health repercussions. Counselors-in-training need to understand the complexities of human rights issues, when and how these rights are violated, and the ways they can engage in advocacy around these issues.

There is a clear connection between social justice, advocacy and human rights. At times, social justice can be combined with advocacy, creating social justice advocacy, which can be described as organized efforts aimed at influencing sociopolitical outcomes, often with or on behalf of vulnerable, marginalized populations. Whether direct system intervention or collaborative advocacy with clients or client groups, counselors-in-training and practicing counselors need to be able to conceptualize and execute advocacy and social justice strategies to mitigate health disparities caused by human rights violations.

The impact of human rights on graduate students

Beginning counseling students are asked to reflect upon their own worldviews and to begin to form a framework from which they will work with clients – a theoretical orientation. It is likely that human rights issues have, in some way, affected students’ lives prior to entering graduate school.

Tracy, for example, is a graduate student who has encountered societal barriers due to their non-binary gender identity (non-binary denotes a gender identity that is not defined in terms of the traditional binary of male or female). Tracy has faced discrimination in schools, was forced to use a bathroom that was not congruent with their identity and has encountered challenges with changing their gender marker on legal documents. This pattern of harassment and obstruction has not only impeded Tracy’s pursuit of their right to a quality education—it has threatened their personal safety. As a counselor in training, Tracy’s worldview and the way they approach counseling will be directly affected by these violations of their human rights.

In contrast, Anthony is a counseling graduate student with numerous identities. As a White, heterosexual, cisgender male, Anthony has experienced very few human rights violations. Yet human rights issues have already had an effect on Anthony’s worldview and theoretical orientation. Because Anthony has not experienced discrimination due to gender identity or sexual orientation, has not experienced poverty, harsh criminal sentencing and does not face obstacles related to legal documents or using public restrooms, his understanding of the relationship between human rights and counseling will be markedly different than Tracy’s.

These two examples demonstrate that when students begin their counselor training, their views on human rights issues have already been shaped by their experiences. A student who has not experienced violations has potentially started to develop a worldview that may not include an understanding of human rights issues. In contrast, a student who has experienced violations not only has an understanding of human rights issues but has been shaped by the difficulties they faced. These divergent experiences will affect the students’ training and may have a significant influence on their work as professional counselors. Thus, it is essential to intentionally address these issues in graduate school.

Learning the effectiveness of clinical interventions in counseling sessions is an established and vital part of graduate students’ training. However, it is equally imperative that counselors-in-training learn how effective—and necessary—it is to work with clients in varying groups and levels, such as families, groups, and at the community or other systemic level. Using a social justice and advocacy approach allows counselors to empower marginalized clients while also working to change the existing external environments for the clients.

For example, as a counselor-in-training, Anthony may work with a 14-year old bisexual, transgender person of color who has experienced time in the criminal justice system. To provide effective counseling, Anthony not only needs to know information about the current justice system, youth under the law, gender, sexuality and racial and ethnic identities and how this impacts his clients health, but also ways to systemically advocate with and on behalf of this client, as an essential part of ethical treatment and attention to social justice.

Anthony can get this critical information by using resources such as Human Rights Watch, an international organization which investigates and reports on human rights-related violations around the world lists several current human rights concerns on their website: Harsh criminal sentencing, racial disparities, drug policy and policing, children in the criminal justice systems, hate crimes, rights of non-citizens, sexual orientation and gender identity, women’ and girls’ rights, and national security, among others.

Human rights and counselor education programs

In many counselor education programs, human rights issues are often introduced in multicultural and diversity courses, as well as in courses that teach about ethical and legal issues within counseling. However, this is not enough. Additional training is needed but is unlikely to be available to students because most education programs do not offer elective courses in human rights issues. It is often the responsibility of course instructors to take the lead by incorporating human rights issues throughout coursework.

Sufficiently educating students on human rights issues will require curricula and systemic change and will also require counselor educators to self-reflect and understand how human rights issues shaped their own worldview, which will, in turn, affect their work with students. If instructors model silence surrounding these issues, students may graduate from counselor education programs lacking the human rights knowledge that is critical to their work as professional counselors. Counselor educators need to teach students that any reflection on the factors that have shaped their worldview is incomplete without examining human rights issues. The extent of the effect of human rights issues on individuals is evident by examining the significant difference in the lived experiences of Anthony and Tracy.

Although scholarly research plays a part in any graduate program, the expectations for master’s level counseling students are different than those in doctoral programs. Some master’s programs may not assign regular research projects to students. In contrast, doctoral students undertake rigorous research into clinical counseling practices and improvement in counselor education and training. Because human rights issues play an important role in these topics, students are likely to encounter clear examples of violations. For example, research examining the counseling experiences of single mothers of color in poverty might explore systemic barriers and oppression these people face, which are direct violations of human rights.

By not giving students significant exposure to research, counselor education programs are missing an opportunity for counselor trainees to be exposed to human rights issues. The old adage “meet clients where they are at” provides a helpful framework for understanding the need to integrate human rights issues into counseling programs. As part of their training, counseling students provide services to a client base that includes members of society who regularly experience human rights violations. Without an understanding of the myriad forms human rights violations can take (see part one of this series for examples) and an awareness of which populations regularly experience issues—and the physical and mental health damage caused—counselors-in-training will be ill-equipped to meet the needs of their clients.

When counselor education programs minimize or outright ignore human rights concepts in students’ training, they could potentially be causing potential harm to future clients. Nonmaleficence — avoiding actions that cause harm — is one of the fundamental ethical principles of counseling set out in the ACA Code of Ethics preamble. Intentionally infusing social justice advocacy and human rights components into the array of coursework will benefit graduate students’ self-efficacy, their clients, and, ultimately, society at large.

 

In the following section, we provide several strategies for graduate students, counselor educators, and counselor education programs to attend to human rights issues and incorporate advocacy and social justice strategies into the classroom:

For graduate students:

  • Mitigate imposter syndrome related to advocacy by managing self-talk, reflecting on accomplishments, normalizing with other graduate students, and practicing self-grace and compassion.
  • Call, text, email, or write to local, state and national legislative representatives on issues that directly impact human rights issues.
  • Engage in continuous self-assessment related to your own advocacy and social justice competency, by using advocacy competency self-assessment tools and surveys.
  • Conduct research that relates to human rights issues and propose/present it at local, regional, and national counseling conferences.
  • Develop and update a list of local, regional, state, and national resources for clients who experience human rights violations.

For counselor education programs and educators:

  • Foster intentional discussions about current human rights issues throughout all areas of counselor training, in addition to diversity, lifespan, and legal/ethical courses.
  • Integrate human rights issues into case studies and clinical examples so graduate students can experience “real world” examples of clients in training programs, prior to practicum and internship experiences.
  • Co-construct specific advocacy and social justice plans as part of coursework that allows graduate students an opportunity to actively participate in these strategies outside of their practicum or internship counseling sessions.
  • Structure clinical experiences that allow students to work with diverse clients and settings. One way to do this might be to work with the program’s clinical coordinator to ensure practicum and internship sites are varied and, if possible, host a variety of clients with a variety of presenting issues.
  • Teach human rights violation assessment as part of a comprehensive biopsychosocial diagnostic evaluation.
  • Allow guest speakers who have experienced human rights violations in the classroom. The personal stories of people who have lived through human rights violations provide a more vivid and compelling understanding than a lecture containing abstract examples. Mentor and model students in research that relates to human rights issues and empower them to propose/present it at local, regional and national counseling conferences.

 

Counselor education programs can also expand outside awareness of human rights issues in a variety of ways:

  • Create statements (with university permission) of support or resolutions that can increase the visibility of and address barriers to human rights issues.
  • Host “days of awareness,” with various human rights topics addressed on different days through flyers, posters or with guest speakers via workshops or panels.
  • Partner with other departments, when possible, in order to cast a wider net of influence and awareness of human rights issues.

 

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Clark D. Ausloos is a doctoral candidate at the University of Toledo. He is a licensed school counselor and currently practices as a licensed professional counselor in a private practice setting in Northwest Ohio. Contact him at clark.ausloos@utoledo.edu.

Ausloos was a member of the American Counseling Association’s Human Rights Committee, as were the authors of the first article in this series.

Taylor M. Nelson is a second-year doctoral student at the University of Toledo. She is a licensed professional counselor in Ohio, working in an inpatient psychiatric hospital setting. Contact her at Taylor.Nelson2@rockets.utoledo.edu.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From the CEO: ACA members are generous and have ‘priviligation’

Richard Yep

Richard Yep, ACA CEO

ACA members are special people. By being part of ACA, members receive Counseling Today and have access to the Journal of Counseling & Development. Members of ACA know they are part of an organization that has literally set the standards for ethics, professional practice, and development of the counseling profession. Members are provided with many opportunities.

In addition to the services and benefits that ACA members receive directly, there is also the advocacy in support of the counseling profession that takes place daily. Our legislative and regulatory concerns are communicated to public policy officials by you and by the ACA Government Affairs team. During this past year, we have had numerous “opportunities” to visit states where the counseling profession was being challenged. This is what your membership provides — the services of a dedicated and experienced team of public policy professionals.

Clearly, the benefits of membership are many. But, today, I’m writing about something you may not have thought about as an ACA member. I am referring to something that is both a privilege and an obligation. I like to call this a “priviligation.”

Simply put, as a member of the world’s largest organization representing professional counselors, you have the “priviligation” of casting a vote for those who will lead the profession in the coming years. The voting cycle runs from Dec. 2 through Jan. 31. ACA members receive an email notification about the election, complete with links to information about who is running at the national, division and region levels of our organization.

You have the control and ability to elect those whom you believe will best serve your interests and those of the profession. I encourage you to take a look at who is running for ACA national, region and division positions. Make your voice heard — by voting!

I often say to candidates who run for ACA positions that I am in awe of their commitment to the profession, their vision, their energy, and their willingness to serve. My feeling is that the membership “thanks” them by casting a ballot. Let this year’s candidates know that you also respect their interest in serving the profession by voting. ACA members will receive an email directly from our election vendor, eBallot, that includes voting instructions, along with a username and password for the eBallot system. Your ACA membership must have been active on Nov. 1 to participate in this year’s voting.

As we head into December, I also need to let you know that the ACA Foundation, a proud professional partner of ACA, is asking all members to consider a donation of any size. The ACA Foundation has seen great success over the years with the programs it supports that benefit ACA’s graduate students and professional members. Most recently, the ACA Foundation has been supporting a “mini grant” program that provides a small amount of funds for professional counselors who have innovative ideas regarding how to serve their clients, students or communities. These small grants are often key to ensuring the success of these endeavors.

So, as we head into the traditional season of giving, I hope you will consider supporting the ACA Foundation in light of the support it has provided to the counseling profession for the past 40 years. More information is available at counseling.org/about-us/aca-foundation.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep.

Be well.

 

From the President: Sustaining the lifeblood of our profession

Heather Trepal

Heather Trepal, the 68th president of the American Counseling Association

December is here, a time of year (along with the months of May and August) when many colleges and universities hold commencement. The prospect of completing a hard-earned master’s or doctoral degree in counseling is both awesome and daunting. Rightly, graduates are proud of the time and personal and financial investments they have put into earning their degrees. We know that counselors spend roughly four years on their undergraduate degrees and then an average of three years on their master’s degrees.

Even after this robust educational preparation, counselors who wish to become licensed spend another two to three years working under supervision. In addition, counselors sometimes work to obtain certifications in their specialty areas or to become eligible for employment in various settings. We are a well-prepared group of professionals!

We are also in high demand, with severe shortages of behavioral health providers in some states (see “Maldistribution: Mental health care in America,” an online exclusive at CT Online). Although we all know that our profession is robust and that we need to continue to educate our growing behavioral health workforce, there is an important gap. To illustrate my point, I want to share an email that I received:

“I’ve noticed something happening with people graduating from the counseling program, not only at my school but all over the state. I’ve noticed many people graduate and are unable to pursue licensure because they can’t afford supervision or they need a full-time job so they can have medical insurance. I’ve noticed people using the school’s insurance and then panicking when they graduate because they can’t go without insurance and they can’t get a full-time position as a counselor intern until they secure a supervisor and get their license, which can take weeks/months. I would love to do advocacy work for this issue, but I don’t know where to begin. I was wondering if you could point me in the right direction? I don’t know if I need to speak to legislators or the school or the board or the ACA.”

Unfortunately, emails like this one are not uncommon. We have many graduate students and new professionals who are concerned about the prospect of launching their careers. In addition to the practical barriers related to employment, finances and medical insurance, there are the complexities of pursuing licensure or certification, including obtaining supervision.

As a counselor educator and supervisor, I am keenly aware of this pressing issue. In fact, this year, Thelma Duffey is chairing a task force to examine ways ACA can support new professionals and early career counselors. The creation of this task force was partly inspired by a project in Thelma’s career class on advocacy for graduate students and new professionals. The task force is collecting data on such issues as new professional compensation across settings (both geographically and among professions); expanding opportunities for counselors in nontraditional settings; and highlighting transferable skills to corporations, health care organizations, industry, and higher education. Recognizing the great needs of counselors before they are licensed to practice independently, I have asked the task force to also explore the post-graduation licensure internship and supervision experiences of our counselors and recommend advocacy directions. I have also asked our Professional Standards Committee to examine the licensure, certification and practice trends for this group of professional counselors.

I am inspired by the advocacy work of one of our ACA members, Summer Allen, who founded the Texas LPC Intern Association. In Texas, pre-independently licensed counselors, or those who have graduated from a master’s program and are working on supervised licensure hours, are called “interns.” The mission of this organization is to “support the professional development of current and future LPC Interns through free resources, support, community, and advocacy.” In fact, one of its first advocacy efforts was aimed at petitioning the state and licensure board to change the title from LPC intern to LPC associate. Please visit txlpcinterns.com to learn more about the organization’s efforts.

It is often said that graduate students are the lifeblood of our profession. The joy of working with them and supporting them on their journey is one of the main reasons that I became a counselor educator. I implore our ACA branches, divisions, regions, and sister organizations to pay attention to this group of professional counselors. If you know of other organizations and grassroots efforts aimed at supporting new professionals and early career counselors, please reach out and let me know.

 

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Follow Heather on Twitter @HeatherTrepal